201 babies might have survived had better maternity care been provided at Shrewsbury and Telford NHS Trust in the period from 2009 to 2019.
This is the devastating conclusion reached by Donna Ockenden, the senior midwife who led a five year investigation into the maternity care at this Trust. The full scale of the failures is set out in a report she released today which follows the largest ever review of maternity care in the NHS. The full report can be found on the Donna Ockenden website, along with the accompanying press release.
In her report, Ms Ockenden pays tribute to the families who were involved in the review and it is because of their bravery in pushing forward their complaints that such a review was able to go ahead. This sad event serves as an important reminder that it is essential that all NHS patients are aware of their right to make a complaint if they are unhappy with or concerned about any aspect of their treatment. It is vitally important that there is transparency and honesty throughout the complaints process as well as any serious incident investigations that follow so that mistakes can be identified and lessons can be learned.
For the families whose children have suffered lifelong injuries as a result of these tragic failings, pursuing a clinical negligence claim for compensation can help to ensure that their child receives the therapy, support and aid they need to thrive. For the families who have suffered loss, the inquest process and pursuit of a clinical negligence claim can ensure they receive the compensation they deserve and offer them the answers to the questions they have been left with as well as helping to ensure that these tragic failings never happen again.
The review examined the cases of 1,486 families and involved reviewing medical records, speaking to families about their care and gathering information from current and former members of staff at the Trust. The report concludes that:
- At least 201 babies would have survived if they had received better maternity care. This tragically consists of 131 still births and 70 neonatal deaths.
- At least 94 children have suffered avoidable harm because of the poor maternity care. Many of these children have suffered from cerebral palsy and hypoxic brain injury.
- 9 mothers sadly died due to major or significant concerns about their care.
The review found that:
- There had been ineffective monitoring of babies’ growth
- There had been a reluctance to perform caesarean sections even when they were clinically mandated
- The failures at the Trust were not challenged internally or externally
- The Trust failed to carry out appropriate serious incident investigations in hundreds of cases
- As a result of the above, there were missed opportunities to learn and serious mistakes were repeated
- There was a shortage of staff and a lack of ongoing training
- There was a culture of not listening to the families involved
Shockingly, the report found that there was a tendency of the Trust to blame mothers for their poor outcomes and in some cases, even for their own deaths. In the report, Ms Ockenden comments that ‘going forward, there can be no excuses, Trust boards must be held accountable for the maternity care they provide. To do this, they must understand the complexities of maternity care and they must receive the funding they require’.
The review identified 15 immediate and essential actions to be undertaken by all maternity services across England although four key pillars have been identified to drive forward improvements in maternity care:
- The provision of a well-staffed workforce which is properly funded
- The need for a well-trained workforce with routine training across all maternity specialisms
- The need for all serious incident investigations to be undertaken in a meaningful and timely manner and for lessons to be learned from any failures
- The importance of listening to families and taking their concerns seriously
NHS England recently announced increased funding of £127 million for maternity services across England but this is still significantly short of the £200-£350 million recommended by the Health and Social Care Select Committee in June 2021. It is clear that urgent action is required to ensure that such poor treatment on such a large scale never happens again.
It is hoped that this review will prove to be an important turning point in the provision of maternity care across England and that all Trusts will review their own practices and systems. It is the duty of the NHS to ensure that all families feel confident that every effort will be made to deliver their babies safely by a trained, motivated and compassionate medical team.
Blog written by Mala Patel, associate in the Clinical Negligence team.